Accessible Unlicensed Requires Authentication Published by De Gruyter April 17, 2018

“When I feel the worst pain, I look like shit” – body image concerns in persistent pain

Oliver Sündermann, Karin Rydberg, Ludwig Linder and Steven James Linton


Background and aims

Persistent pain is a pervasive condition that is often associated with a distorted body image. Most research into pain and body image investigated neural or physiological correlates (e.g. phantom limb pain), and much less is known about the psychological experience of body image changes in response to pain such as appearance concerns. The aim was to examine body image concerns in people with persistent pain, in particular appearance concerns and related coping behaviours and appearance-related emotions such as anger and shame.


Design was cross-sectional and data was collected through in-depth semi-structured interviews with people suffering from persistent musculoskeletal pain (n=7; six females; age=19–56), and analysed with inductive thematic analysis (TA).


Two main themes were identified: “Relationship to the painful body” and “Dissatisfaction with the body”, each containing three subthemes, along with the side-theme “Appearance concerns affected by pain and mood”. All participants reported appearance concerns, predominantly about their weight and related coping behaviours such as avoidance of mirrors, exercising or dieting and pain-induced mood changes that were associated with a negative body image.


People with persistent pain report appearance concerns, often related to pain-induced negative mood changes, and reduced functioning. It remains unclear to what extent attitudes towards the body change over time in accordance with pain. A wider concept of body image is required, including the perception of reduced functioning, related appraisals (e.g. “I look weak and old”) and appearance investment.

  1. Authors’ statements

  2. Research funding: The study was supported by a grant from The Swedish Foundation for Humanities and Social Sciences.

  3. Conflict of interest: None.

  4. Informed consent: All participants provided written consent to their participation.

  5. Ethical approval: The study was approved by the Regional Ethics Board, Uppsala (2015/480/1).


[1] Cash TF. Body image: past, present, and future. Body Image 2004;1:1–5.1808913610.1016/S1740-1445(03)00011-1 Search in Google Scholar

[2] Hrabosky JI, Cash TF, Veale D, Neziroglu F, Soll EA, Garner DM, Strachan-Kinser M, Bakke B, Clauss LJ, Phillips KA. Multidimensional body image comparisons among patients with eating disorders, body dysmorphic disorder, and clinical controls: a multisite study. Body Image 2009;6:155–63.10.1016/j.bodyim.2009.03.00119410528 Search in Google Scholar

[3] Ramachandran VS, Hirstein W. The perception of phantom limbs. The DO Hebb lecture. Brain J Neurol 1998;121:1603–30.10.1093/brain/121.9.1603 Search in Google Scholar

[4] Lewis JS, Kersten P, McCabe CS, McPherson KM, Blake DR. Body perception disturbance: a contribution to pain in complex regional pain syndrome (CRPS). PAIN® 2007;133:111–9.10.1016/j.pain.2007.03.013 Search in Google Scholar

[5] Luomajoki H, Moseley GL. Tactile acuity and lumbopelvic motor control in patients with back pain and healthy controls. Br J Sports Med 2011;45:437–40.10.1136/bjsm.2009.06073119553222 Search in Google Scholar

[6] Moseley GL. I can’t find it! Distorted body image and tactile dysfunction in patients with chronic back pain. Pain 2008;140:239–43.10.1016/j.pain.2008.08.00118786763 Search in Google Scholar

[7] Flor H, Braun C, Elbert T, Birbaumer N. Extensive reorganization of primary somatosensory cortex in chronic back pain patients. Neurosci Lett 1997;224:5–8.913268910.1016/S0304-3940(97)13441-3 Search in Google Scholar

[8] Moseley GL, Flor H. Targeting cortical representations in the treatment of chronic pain: a review. Neurorehabil Neural Repair 2012;26:646–52.10.1177/154596831143320922331213 Search in Google Scholar

[9] Osumi M, Imai R, Ueta K, Nobusako S, Morioka S. Negative body image associated with changes in the visual body appearance increases pain perception. PLoS One 2014;9:e107376.10.1371/journal.pone.010737625210738 Search in Google Scholar

[10] Purser MM. Chronic pain and body image (Doctoral dissertation) [Internet]. Unpublished; 2010. Available from: . Search in Google Scholar

[11] Sündermann O, Wheatley J, Veale D. ‘If you have good skin, you are god. If you have bad skin, you are a piece of rubbish’. Mastery of shame and anger in treatment-resistant body dysmorphic disorder: a single case study. Cogn Behav Ther 2016;9:1–18. Search in Google Scholar

[12] Crowe M, Whitehead L, Jo Gagan M, Baxter D, Panckhurst A. Self-management and chronic low back pain: a qualitative study. J Adv Nurs 2010;66:1478–86.2049201810.1111/j.1365-2648.2010.05316.x Search in Google Scholar

[13] Mond J, Mitchison D, Latner J, Hay P, Owen C, Rodgers B. Quality of life impairment associated with body dissatisfaction in a general population sample of women. BMC Public Health 2013;13:920.10.1186/1471-2458-13-920 Search in Google Scholar

[14] Neumark-Sztainer D, Paxton SJ, Hannan PJ, Haines J, Story M. Does body satisfaction matter? Five-year longitudinal associations between body satisfaction and health behaviors in adolescent females and males. J Adolesc Health 2006;39:244–51.1685753710.1016/j.jadohealth.2005.12.001 Search in Google Scholar

[15] Pruzinsky T. Enhancing quality of life in medical populations: a vision for body image assessment and rehabilitation as standards of care. Body Image 2004;1:71–81.10.1016/S1740-1445(03)00010-X18089142 Search in Google Scholar

[16] Proulx K. Experiences of women with bulimia nervosa in a mindfulness-based eating disorder treatment group. Eat Disord 2007;16:52–72.10.1080/10640260701773496 Search in Google Scholar

[17] Veale D, Eshkevari E, Kanakam N, Ellison N, Costa A, Werner T. The appearance anxiety inventory: validation of a process measure in the treatment of body dysmorphic disorder. Behav Cogn Psychother 2014;42:605–16.2382348510.1017/S1352465813000556 Search in Google Scholar

[18] Brohede S, Wingren G, Wijma B, Wijma K. Validation of the body dysmorphic disorder questionnaire in a community sample of Swedish women. Psychiatry Res 2013;210:647–52.10.1016/j.psychres.2013.07.019 Search in Google Scholar

[19] Sullivan MJ, Bishop SR, Pivik J. The pain catastrophizing scale: development and validation. Psychol Assess 1995;7:524.10.1037/1040-3590.7.4.524 Search in Google Scholar

[20] Sullivan MJ, Thorn B, Haythornthwaite JA, Keefe F, Martin M, Bradley LA, Lefebvre JC. Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain 2001;17:52–64.10.1097/00002508-200103000-0000811289089 Search in Google Scholar

[21] Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77–101.10.1191/1478088706qp063oa Search in Google Scholar

[22] Guest G, MacQueen KM, Namey EE. Chapter 1. Introduction to thematic analysis. In: Applied Thematic Analysis. London, UK: SAGE, 2012. Search in Google Scholar

[23] Wideman TH, Sullivan MJ. Reducing catastrophic thinking associated with pain. Pain 2011;1:249–56. Search in Google Scholar

[24] Marques L, LeBlanc N, Weingarden H, Greenberg JL, Traeger LN, Keshaviah A, Wilhelma A. Body dysmorphic symptoms: phenomenology and ethnicity. Body Image 2011;8:163–7.10.1016/j.bodyim.2010.12.00621354876 Search in Google Scholar

[25] Veale D. Advances in a cognitive behavioural model of body dysmorphic disorder. Body Image 2004;1:113–25.10.1016/S1740-1445(03)00009-3 Search in Google Scholar

[26] Crombez G, Van Damme S, Eccleston C. Hypervigilance to pain: an experimental and clinical analysis. Pain 2005;116: 4–7.1592738710.1016/j.pain.2005.03.035 Search in Google Scholar

[27] Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: a literature review. Arch Intern Med 2003;163:2433–45.10.1001/archinte.163.20.243314609780 Search in Google Scholar

[28] Linton SJ, Bergbom S. Understanding the link between depression and pain. Scand J Pain 2011;2:47–54.2991373410.1016/j.sjpain.2011.01.005 Search in Google Scholar

[29] Linton SJ, Flink IK, Schrooten MG, Wiksell R. Understanding co-occurring emotion and pain: the role of context sensitivity from a transdiagnostic perspective. J Contemp Psychother 2016;46:129–37.10.1007/s10879-016-9323-x Search in Google Scholar

[30] Baker JD, Williamson DA, Sylve C. Body image disturbance, memory bias, and body dysphoria: effects of negative mood induction. Behav Ther 1995;26:747–59.10.1016/S0005-7894(05)80043-7 Search in Google Scholar

[31] Cash TF, Santos MT, Williams EF. Coping with body-image threats and challenges: validation of the Body Image Coping Strategies Inventory. J Psychosom Res 2005;58:190–9.10.1016/j.jpsychores.2004.07.00815820848 Search in Google Scholar

[32] Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain 2006;10:287–333.10.1016/j.ejpain.2005.06.00916095934 Search in Google Scholar

[33] Greenwood KA, Thurston R, Rumble M, Waters SJ, Keefe FJ. Anger and persistent pain: current status and future directions. Pain 2003;103:1–5.1274995210.1016/S0304-3959(03)00132-5 Search in Google Scholar

[34] de Souto Barreto P, Ferrandez A-M, Guihard-Costa A-M. Predictors of body satisfaction: differences between older men and women’s perceptions of their body functioning and appearance. J Aging Health 2011;23:505–28.10.1177/089826431038637021041294 Search in Google Scholar

Received: 2017-11-14
Revised: 2018-03-11
Accepted: 2018-03-18
Published Online: 2018-04-17
Published in Print: 2018-07-26

©2018 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved.